Lou Friedman, PT and Scott Capozza, PT, The Benefits
of Physical Therapy for Cancer Patients
January 10, 2010
Welcome to Yale Cancer Center Answers with Drs. Ed Chu and Francine Foss, I am Bruce Barber. Dr. Chu is Deputy Director and Chief of Medical Oncology at Yale Cancer Center and Dr. Foss is a Professor of Medical Oncology and Dermatology specializing in the treatment of lymphomas. If you would like to join the conversation, you can contact the doctors directly. The address is canceranswers@yale.edu and the phone number is 1888-234-4YCC. This evening Ed welcomes Scott Capozza and Lou Friedman, two physical therapists who specialize in working with cancer patients. Scott sees his patients through the Connecticut Challenge Survivorship Clinic and Lou focuses his time assisting orthopedic and breast cancer patients at Yale.
Chu
I think a lot of people don't really appreciate all the different
types of resources that are available once the diagnosis of cancer
is made and once cancer treatment is initiated. Lou, perhaps you
can start off by describing for us what role the physical therapist
can play as part of that multidisciplinary approach to treating
patients with cancer?
Friedman
Certainly, I am glad to answer that. I think it depends on at what
point the first contact is made. Scott will see patients
almost on a wellness issue, whereas they are coming in because they
perhaps have a problem with certain activity, they want to improve
their activity, exercise, and their lifestyle, and they are looking
for some consultation and some guidance. In our outpatient
clinic, we see patients that actually have problems. They
might have problems with moving their shoulders, or
lymphedema. They have seen a physician, they have a medical
diagnosis and we set up a treatment plan for them. I would
say one of the keys, whether it's in my clinic or when Scott gets
them, is really education and guidance. A lot of patients are
looking for answers. They are not quite sure what they can
and can't do after a diagnosis of cancer and after their treatment,
and I think one of the biggest roles we play is helping guide them
through that process.
Chu
In your experience, what are the main types of cancers for which
physical therapy seems to play an important role?
Friedman
I can answer that from our clinic. We see a wide variety, we
see patients who have had breast cancer, they may have had surgery
for their breast cancer and it could be any combination of issues
with problems with their shoulders, or difficulty with activities
of daily living. We see patients with lymphedema, which is a
swelling of the arm. We also see individuals who have had
ovarian and uterine cancer, and they might have issues with their
legs, swelling in their legs or difficulty with their mobility. We
also see individuals with head and neck cancer that have
difficulties moving their neck, or moving their
shoulders.
Chu
Scott, what type of cancer patients do you see in your clinic?
Capozza
We see patients who have had all types of cancer. Primarily,
I would say we see breast cancer survivors, but we have seen
survivors of leukemias and lymphomas, survivors of prostate
cancer,
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and colon cancer. What we do when somebody comes in, as Lou was
talking about, is I give them a lot of guidance as far as where
they are and help them to design an exercise program because a lot
of people didn't exercise prior to their cancer diagnosis and now
they feel that they need to and they don't know how to start.
One of the other big side effects of cancer treatment that is very
prevalent in cancer survivors is fatigue, so I talk a lot with
patients about how to battle that fatigue and how to get through
that so that they can start living an active life. If they come
into our clinic and I notice that they do have limitations in their
strength or their range of motion, especially for the breast cancer
survivors, then I definitely make the referral to Lou and to the
outpatient clinics so that they can get the more hands on treatment
that they need.
Chu
Scott, in your clinic, which is the Connecticut Challenge
Survivorship Clinic, have most of the patients completed their
therapy already and are now dealing with the consequences, the
sequelae, of either the cancer and/or the cancer treatment?
Capozza
Yes, that's well put. We work with people who are done with
their active treatment; post-surgery, post-radiation, or
post-chemotherapy. For some of the women who are on hormonal
therapy or Herceptin, we do see them and we can see a survivor from
six to eight weeks after they complete treatment all the way
to 10, 15, 20 years after they have completed treatments.
There really isn't a cap, so to speak, as to when we would see a
survivor.
Chu
Lou, in your clinic it sounds like you see patients who may have
been diagnosed right upfront with their cancer and are undergoing
active treatment, is that correct?
Friedman
We will see individuals that are currently undergoing radiation,
currently undergoing treatment, so that does force us to modify our
treatment plans according to their general endurance level. They
may be recently postoperative, so we can't push them too hard, we
really do have to adjust our treatment plan according to their
individual needs.
Chu
It sounds like, just hearing the different types of symptoms that
you two treat, that really almost any cancer patient, truthfully,
once given the diagnosis, once they are undergoing active therapy,
really could benefit from at least an initial consultation with a
physical therapist?
Capozza
Yeah, I would like to answer that briefly. We are seeing that more
and more, and I believe that patients are advocating for
themselves. Physicians are much more willing now to refer patients,
not that they weren't willing before, but it comes to
survivorship. The focus used to be on the diagnosis and
survival, and with the advances in care we are seeing many more
survivors, and as a result of that we are seeing patients that have
say musculoskeletal issues and now want to have that addressed, and
also their concerns with the quality of their life having survived.
We are definitely
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seeing an influx and we are seeing a willingness of the medical team all in all to refer patients to our clinic so that the patients can move on.
Chu
As you may know, my area of interest has been in the treatment of
patients with colorectal cancer, and now colon cancer, breast
cancer, and many other cancers are becoming more of a chronic
disease, a chronic illness, and then symptom management,
maintaining quality of life, comes to the forefront in terms of how
we begin to approach patients.
Capozza
That's very true, and when someone comes to our Survivorship
Clinic, you are absolutely right, the whole idea of quality of life
is important and that it's not enough to just make it through their
treatments, but once their treatments are done, people want to get
back to their life and we have this idea of the 'new normal' and
what its like to be a cancer survivor. I know that at our clinic,
we also have a dietician, a social worker, and a nurse practitioner
to talk about all of those different areas of need for our
survivors. So its not just the physical, its also the
emotional and the medical that need to be maintained, and so many
people have questions about their diet as well, so its all rolled
into one.
Chu
Lou, in your clinic, one of the areas focused on is lymphedema,
it's kind of a complicated word, and so can you explain to us what
lymphedema is?
Friedman
Certainly, and it's somewhat of a complicated concept, but I will
simplify it. Essentially, lymphedema is a build up of fluid
in the body tissue where it doesn't belong. To understand
that Dr. Chu, obviously the listeners need to understand fluid
mechanics and I will briefly go over that. The heart pumps oxygen
rich fluid to all areas of the body, every nook and cranny.
The issue then is getting it back to the heart, if all the fluid
came out of the heart and didn't return, the patient wouldn't
survive long. So, it comes out one way, which is the
arteries, and it comes back two ways, which are the veins and then
the lymphatic system. So whatever the veins don't bring back,
it is the job of the lymphatic system to bring back. The
lymphatic system has structures in it called lymph nodes, and the
unfortunate part of these lymph nodes is that cancer tends to like
lymph nodes. So, when there is surgery, the surgeons have to
look for cancer in the lymph nodes and often times have to remove
the lymph nodes to get all the disease out of the body. What
that does is it clogs up the return system and that builds up fluid
in the body tissues.
Chu
Are there specific types of cancer in which we see a higher
incidence of lymphedema?
Friedman
In our clinic we see three main types, we see patients who have had
surgery for breast cancer, so they would have lymphedema or
swelling in the arm, the chest wall, and often times the
armpit. We see patients who have had ovarian cancer or
uterine cancer, and lymph nodes have been taken
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out from the pelvic area and you may see a build up of fluid in the legs. We also see a number of patients who have had head and neck cancer, and so they have what's called a neck dissection and they take lymph nodes out the head and neck area, and that will cause fluid to build up in the neck area and the facial area.
Chu
Is there any way to predict which patient will or will not develop
this build up of fluid?
Friedman
Unfortunately not, its one of those things that we have tried to
study but it's just very hard to study. I can tell you that
there are some risk factors; a person needs to maintain their body
weight, infection is a risk factor, so by all means a person
needs to not get an infection, they have to be very cautious about
their skin care. I would say that an injury, whether it be a
traumatic injury or an overuse injury, those are some potential
risk factors that could produce lymphedema in a body, but we don't
really have an answer that says if you do XYZ you won't get
it. That doesn't exist.
Chu
Once lymphedema is diagnosed in a patient and they suffer the
consequences, the symptoms, and they come to see you, what are the
different approaches that you will take to treat that process?
Friedman
Thank you, that's a good question and it's a very global approach.
We have to do a lot of different things because there really is no
one thing that is the answer, and it's different for every
person. We use a combination of techniques, one is called
manual lymph drainage, and it's a hands-on technique where we are
trying to move the lymphatic fluid out of the area that's
congested, if you will, with the fluid, and direct it back to the
heart or around the area that is impaired. We will use
certain types of compression, whether it is a compression garment
or a wrap called the short stretch bandage. A lot of it is
education, as we talked about, for preventing infections, so
education of skin care, and we do a lot of education on the
appropriate type of exercise. Exercise is good for
lymphedema, but over exercise is not good for lymphedema.
Education, as I mentioned earlier, seems to be a very important
part of what we do.
Chu
Many-many years ago, there was a machine that would try to pump out
the fluid back into the circulation, is that still being used at
all or is that kind of passé?
Friedman
Well we use it in very rare case, I shouldn't say rare, but in a
small number of cases. The original design of that pump was
for venous insufficiency and it works very well for venous
insufficiency. People tried to convert it over to use for
lymphedema, and one of the problems is that the pump really will
move fluid. Lymphedema tends to be protein rich, and you have
to do the hands on care to open up those pathways. What will happen
potentially with the pump is that you can move fluid out of the
lower part of the leg but have it congested in the upper part of
the limb, whether it is in the upper arm or in the upper part of
the leg.
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Chu
And are there any new ways that you are aware of that we can begin
to identify? You mentioned the risk factors, but are there any new
sophisticated technologies that might be used to identify which
patient down the road will develop lymphedema?
Friedman
To the best of my knowledge there isn't. There are some new
machines that look at impedance, which is electrical flow, and they
look to see if one arm has higher impedance versus the other.
To my knowledge that hasn't proved effective yet. I don't
know whether that is something that will eventually be of use.
Chu
Something for you to be aware of Lou, is Dr. Susan Higgins in
radiation oncology is about to open up a clinical study, actually
using one of these machines to measure the impedance values, and I
guess its in women with breast cancer, but I think she is now
thinking of opening it up for patients with ovarian cancer, uterine
cancer, and maybe even melanoma because I guess they also may be at
increased risks if they had a lymph node dissection. That may
be something that you and Dr. Higgins and her team could hook up
on.
Friedman
Certainly, hopefully down the road that will show to be of
value.
Chu
That should be quite interesting. Let's take a break for a
medical minute. You are listening to Yale Cancer Center
Answers and I am here discussing the important role of supportive
care and physical therapy for patients with cancer with Scott
Capozza and Lou Friedman.
Chu
Welcome back to Yale Cancer Center Answers. This is Ed Chu
and I am here in the studio this evening with Scott Capozza and Lou
Friedman, both of whom are physical therapists at Yale Cancer
Center and Yale-New Haven Hospital. Scott, why don't we have
a discussion about the role of exercise and physical fitness and
where that fits into treating patients with cancer?
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Capozza
Well I think exercise and fitness fit in with cancer patients
throughout their treatment and their journey into survivorship as
well. A patient that is able to do a little bit of exercise
during their treatments might actually find that they recover a
little bit quicker from their treatments, and I think it helps them
from a mental standpoint too. One of the tough things about
being a cancer patient is you feel like you lose control of what's
going on in your life, and so for a cancer patient to at least be
able to take control of that and say, you know what, I am still
going to try to go out and try to go for a 20 minute or 30 minute
walk or something along that line, then I think that empowers the
patient a little bit more and it helps them mentally as well as
physically to get through their treatment. And then as the cancer
patient makes that transition into cancer survivor, post treatment,
its very important to continue with exercise and fitness because
you want to be able to reduce the risk of recurrence and try to get
back to the way your life was and help get rid of some of those
side effects from the chemotherapy, radiation, or surgery. It
helps with circulation and overall body healing, and maintaining
your weight, which are all very important things to do. That's why
exercise is such an important part of the cancer process.
Chu
Its interesting that you mention being physically active as a
cancer patient, exercising, really has a positive impact on
ultimate prognosis. This really is an important issue for listeners
out there to take home.
Capozza
Absolutely, and as cancer patients can attest, obviously there are
going to be some days where the cumulative effects of chemotherapy
will catch up to them, or the cumulative effect of radiation will
catch up to them, and there will be some days where you wont be
able to exercise, or based on the surgery that you had or if your
levels are really low. And that's a conversation that the patient
has to have with their doctor about whether exercise is safe, and
that sort of thing. But if your doctor says, yeah you are okay to
do some form of exercise, then I think it helps with the body
healing itself from the surgeries, from radiation, and from
chemotherapy, and then also the mental aspect of it as well.
Chu
Scott, maybe you can help our listeners with respect to what type
of physical exercise we are talking about? Is it strenuous exercise
that you would see people out in the gyms doing, or runners?
Capozza
For most cancer survivors the gold standard is to try to do
something five times a week, and that can be walking at a good
clip, walking at a pace where you are able to elevate your heart
rate and maintain that elevated heart rate. You can also do biking,
swimming, or some running. We don't necessarily need to have
people go out and train for the Ironman Triathlon or for a marathon
to that extent, but a combination of cardiovascular work is really
good and also a little bit of strength training as well, especially
for some women who are put on hormone therapies that put them at
risk for osteopenia and osteoporosis. They want to maintain good
bone strength, so weightbearing
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activities like walking are good, and then strength training with the upper body is good to maintain that bone density to help them as they go through.
Chu
How about the case where a patient is undergoing active
chemotherapy, and as you mentioned earlier, a lot of those patients
will experience fatigue, so how do you get them to do maybe not the
strenuous exercise, but to do some form of exercise?
Capozza
When patients are going through chemotherapy they will figure out
during their cycle when their good days are going to be and when
their not so good days are going to be; when those cumulative
effects will catch up. So on those days where they know that they
are going to be feeling okay, it may be as simple as writing it
down in their daily planner, or putting it in their planner on
their BlackBerry or iPod, or whatever it might be. If you write it
down, it then holds you a little more accountable to go out and
exercise, even if it is just a 20 or 30 minute walk. Maybe you
contact a friend, family member, or a neighbor to say, hey, you
know what, I really need to go for a walk today but I really need
your help, I need your encouragement to help me get out the door,
so lets meet at 3 o'clock or 4 o'clock, and lets go do that.
Eliciting the support of family and friends is a really good way to
keep you honest and try to help you stay on task with that.
Chu
Again, these recommendations should hold for everyone who has a
diagnosis of cancer. I am sure there are some listeners out there
who have cancer, have finished their treatments, and prior to that
weren't very active and now are asking, how can I become physically
fit and exercise like you are suggesting?
Capozza
And that's one of the biggest things that I see at our Survivorship
Clinic, people who did not exercise prior to their cancer diagnosis
and then they go through their treatments and they realize that
they don't want to go through this again, and they want to be able
to prevent a recurrence and get back to as normal of a life as
possible. They realize that exercise and nutrition are such
important components of that, but they don't know how to start
because they didn't have that experience previously. That's
one of the things that we can do at the Survivorship Clinic, we
give them some counseling and help design an exercise program for
them so that it helps them move forward from there.
Chu
You have a very interesting perspective because you are a cancer
survivor.
Capozza
I am.
Chu
I understand that you have now hit the 10-year mark, so
Congratulations.
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Capozza
Thank you.
Chu
That really is a tremendous accomplishment. So you have a
very interesting perspective, one as a cancer survivor, but also as
a physical therapist. Can you tell us a little about that?
Capozza
I was diagnosed with cancer when I was 22 and I was in graduate
school for physical therapy, and I was actually a runner.
Previously, I ran competitively cross-country and did track in high
school and college. So I did exercise previously to my cancer
diagnosis so when I was diagnosed it really took me by surprise
because I didn't think that I would ever get cancer because I ran
so much and I remember after surgery my doctor said you can't run
for six weeks afterwards and he said allow your body to heal, and
unfortunately, I didn't listen to him and I started running after
four weeks. I remember during my first consultation with my
oncologist for chemotherapy, he sat me down and was talking to me
about the three drugs I was going to be on, and that I was going to
lose my hair, and I would be nauseous, and here are all these side
effects, did I have any questions? And my first question to
him was, can I still run? And I don't think that a lot of
patients had asked him that question before because the look on his
face told me that I took him by surprise, but I knew for me,
physically, I needed to do it in order to heal and maintain that
normalcy that was part of my life. I knew I needed to do it
mentally too because I needed to prove to myself that I wasn't
losing the fight against cancer, and so I think I have taken that
perspective and I have tried to bring it to my patients at the
Survivorship Clinic and tell them that, listen, anybody can do this
on some level. Like I said, you don't have to be a marathon
runner, you don't have to go out and bike 100 miles every single
day, but to be able to do something empowers you as you go through
your battle with cancer.
Chu
Terrific. And as you have mentioned, you are a key member of
the Connecticut Challenge Survivorship Clinic and in that clinic
patients will see different individuals, a nutritionist, an
exercise physiologist, a physical therapist, yourself, social
workers, and a physician, and then at the end of that visit, a
treatment summary is prepared. Tell us what goes into that
treatment summary?
Capozza
What goes into the treatment summary is all four other disciplines;
the nurse practitioner, the social worker, the dietician, and
myself. We write our narratives, we write up our plan of
care, so to speak, and its all formulated together into one
document which is then sent to the patient and can also be sent to
any and all of the patient's physicians, the primary care
physician, oncologist, radiation oncologist, whoever the patient
wants us to send that information to, and so that is a hard copy
that the patient can have and it's a nice little review of what we
talked about. Then, as part of our clinic, we have a
two-month follow-up and a four-month follow-up, so it gives us
an
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opportunity to check back in with the survivor and the survivor to check back in with us to say, hey, you know, two months ago we talked about starting the walking plan and going to the gym once or twice a week, how is that going? Is that going well, or is that not going well? Then we can brainstorm on further ideas to help them through.
Chu
Great. Let's get back to Lou here. One of the
complaints that I hear quite frequently from our cancer patients is
back pain, and that could either be because of the cancer or
because of benign causes, and I am just curious, how do each of you
approach patients with back pain and what are kind of the general
approaches that you take to try to help to relieve that
symptom?
Friedman
In my role treating orthopedic patients, we see a lot of back pain
and I actually have not seen a lot of individuals in my clinic with
back pain related to a cancer diagnoses. I can answer that a
little bit just from a general back pain perspective, and back pain
is one of those things that really fits into what we have been
talking about here today, because one of the keys for back pain is
exercise. Looking at the right amount of flexibility in the
body, the right amount of strength of the abdominal muscles,
tightness of the legs and hips, certainly can produce back pain,
often times its our postures that we maintain hours on end without
reversing that posture. I would imagine that from that
perspective, if it's musculoskeletal, it would really fall into the
same category as general orthopedic back pain.
Chu
I have to say I had disc disease many years ago and the
alternatives where either surgery or physical therapy.
Needless to say I opted for the intense physical therapy and it was
really quite remarkable how doing all of those various exercises
that you just mentioned, probably within two months, the back pain
and the paresthesias disappeared.
Friedman
In my early 20s I hurt my back at work, and this was before I was a
physical therapist, and lucky for me I learned how to manage it on
a conservative basis. I can tell you that if I go four or
five days without doing my specific back exercises, my back will
start to hurt and if I can keep on it I can keep it completely at
bay and do just about anything I want to do.
Chu
It's amazing how quickly the time has gone, we have got about 60
seconds, what final piece of advice can you give to our listeners
out there who would like to take that first step in becoming more
active and improving their overall health, but need some
urging?
Capozza
As you have gone through your cancer treatment and you are a
survivor now, you need to look at that opportunity to say, this is
my second chance to really do something good here, and so if you
are looking to get into a fitness program or start exercising,
there are programs out there like our Survivorship Clinic to help
you with that. If you do have more physical side effects from
your treatment such has lymphedema, scar tissue, or limitations in
range of motion, then that's a great
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opportunity for a physical therapist to work with you and really get their hands on you to help you through that.
Chu
Great. You have been listening to Yale Cancer Center Answers
and I would like to thank our guests this evening Scott Capozza and
Lou Friedman for joining me. From Yale Cancer Center, this is
Ed Chu wishing you a safe and healthy week.
If you have any questions or would like to share your comments, you can go to yalecancercenter.org where you can also subscribe to our podcast and find written transcripts of past programs. I am Bruce Barber and you are listening to the WNPR Health Forum from Connecticut Public Radio.